Many healthcare facilities in developing countries lack the equipment and trained personnel required for etiological diagnosis of STIs (using laboratory tests to identify the causative agent). Where no laboratories or point-of-care diagnostic tests are available, a syndrome-based approach to the management of STI patients should be promoted. With the syndromic management approach, accessible, affordable, and effective management of individuals with STIs relies on utilization of flowcharts (algorithms) for each STI syndrome. The flowcharts enable diagnoses of common STI syndromes, provision of current country-specific appropriate treatments, advice on the management of sexual partners, and emphasis on the importance of same-visit HIV testing. Preferably, the flowcharts should be based on local etiological and antimicrobial susceptibility data. Otherwise, WHO treatment recommendations should be used.

Syndromic case management enables all trained first-line service providers to diagnose an STI syndrome and treat patients on the patient’s first visit, helping to prevent the further spread of STIs where etiological diagnosis is not available. Syndromic case management also includes patient education (about the infection, how STIs are transmitted, risky sexual behavior and how to reduce risk), partner management and the provision of condoms.

Treatments based on this approach is chosen to cover the major pathogens responsible for the syndromes in the specific geographical area. To make this determination, a laboratory analysis of the syndromes is made and the pathogens for each syndrome are identified. This means that the management of individual patients will not depend on laboratory investigation. Periodically, the syndromes are reviewed for two reasons: to ensure that the antimicrobial choices are still valid, and to monitor any antimicrobial resistance. If this review is not conducted, the syndromic approach loses its scientific basis.

syndrome mgt sti table 1

Urethral discharge

Male patients complaining of urethral discharge and/or dysuria (pain during urination) should be examined for evidence of discharge. The major STIs causing urethral discharge are gonorrhea and chlamydia. In the syndromic management, treatment of a patient with urethral discharge should adequately cover these two STIs. Where reliable laboratory facilities are available, a distinction can be made between the two organisms and specific treatment instituted. Persistent or recurrent symptoms of urethritis (inflammation of the urethra) may result from drug resistance, poor compliance with the treatment or reinfection. Where symptoms persist or recur after adequate treatment for gonorrhea and chlamydia in the patient and his/her partner(s), the patient should be treated for trichomoniasis if cases of this STI is found in the geographical location of the patient.

Vaginal discharge

A spontaneous complaint of abnormal vaginal discharge (in terms of quantity, color or odor) is most commonly a result of a vaginal infection but can also be caused by an STI such as chlamydia and gonorrhea. Detecting these STIs are difficult because a large proportion of women with gonorrhea or chlamydia are asymptomatic. Among women presenting with discharge, one can attempt to identify those with an increased likelihood of being infected with gonorrhea and/or chlamydia. To identify women at greater risk of having a STI, an assessment of a woman’s risk status may be useful, especially when risk factors are adapted to the local situation. Knowledge of the local prevalence of gonorrhea and/or chlamydia in women presenting with vaginal discharge is important when making the decision to treat for STI. The higher the prevalence, the stronger the justification for treatment. Women with a positive risk assessment have a higher likelihood of cervical infection than those who are risk negative. Women with vaginal discharge and a positive risk assessment should, therefore, be offered treatment for gonorrhea and chlamydia.

In some countries, syndromic management flowcharts have been used as a screening tool to detect STIs among women not presenting with a genital complaint (e.g. in family planning settings). While this may assist in detecting some women with STIs, it is likely that there will be substantial overdiagnosis.

Genital Ulcer Disease (GUD)

The relative prevalence of infections causing genital ulcers varies considerably in different parts of the world and may change dramatically over time. Distinguishing between diseases with similar symptoms of genital ulcers is often inaccurate. Symptoms and patterns of genital ulcers may be further changed in the presence of HIV infection.

After examination to confirm the presence of genital ulcers, treatment appropriate to local settings and antimicrobial sensitivity patterns should be given. In areas where both syphilis and chancroid are prevalent, for example, patients with genital ulcers should be treated for both conditions at the time of their initial presentation, to ensure adequate therapy in case of loss to follow-up.

Reports from Latin America indicate that genital ulcer disease (GUD) is more frequently a result of herpes simplex virus type 2 (HSV2) infections. This has implications for the efficacy of the syndromic management of GUD if specific antiviral treatment of HSV-2 is not considered.

PAHO/WHO response

  • WHO has developed a 7-module training program for the syndromic management of sexually transmitted infections. The training program is for clinicians and service providers whose normal duties include first-level diagnosis and treatment of patients and those who work as outreach providers, counsellors or educators at any first-contact health facility
  • WHO has developed Guidelines for the Management of Sexually Transmitted Infections to improve the management of STIs by focusing on the syndromes of genital ulcers and vaginal discharge